Some medical services and medications may need a prior authorization (PA), sometimes called a “pre-authorization” or an “OK," before care or medication can be covered as a benefit. Ask your provider to go to Prior Authorization Requests to get forms and information on services that may need approval before they prescribe a specific medicine, medical device or procedure.
How It Works
If the service you need requires a prior authorization, you will need to ask your PCP to get an OK from BCBSTX to make sure the service is covered. This means that both BCBSTX and your PCP (or specialist) agree ahead of time that the services or care you need are medically necessary. “Medically necessary” refers to getting care that:
- Protects life
- Keeps you from getting seriously ill or disabled
- Finds out what’s wrong or treats a disease, illness, or injury
- Helps you do things like eating, dressing, and bathing
Your child's PCP may send you to a different provider, including a specialist, for special care or treatment. A referral to an in-network specialist is not needed. You can see out-of-network Medicaid specialists for medically necessary services. When the provider is out-of-network, you can work with your service coordinator to get an OK.
Be sure to get an OK from us for any medical services that require a prior authorization before the service is performed or we may not pay for the services. Some services that do not need an OK are:
- Family planning
- OB/GYN services – You must choose providers in your health plan’s network.
- Emergency care
- Texas Health Steps medical checkup appointments
- Early Childhood Intervention (ECI)
- Sexually Transmitted Infections (STI)/HIV
- Case Management for women and children
- Behavioral health and substance use services
Call the Customer Advocate Department if you have questions about services that need an OK or if you need help making an appointment with a specialist.
Need to locate a provider? Search the Provider Finder®.
How Does BCBSTX Approve a Request?
Our doctors and staff make decisions about your care based on need and benefits. They will also use tools such as medical codes, policies and clinical criteria to prescribe the most appropriate treatment. Your PCP will order any medically necessary services. BCBSTX will only pay for medically necessary covered services.